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EXPONENTIAL SURGE IN ANTIREFLUX SURGERY UTILIZATION IN THE UNITED STATES: RESULTS FROM A 25-YEAR NATIONWIDE POPULATION-BASED ANALYSIS
Daniel M. Simadibrata
*1, Ronnie Fass
21Department of Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH; 2Division of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
Introduction: Antireflux surgery, particularly surgical fundoplication, has long been a cornerstone treatment for gastroesophageal reflux disease (GERD) in the United States. However, between 2009 and 2013, utilization rates showed a notable decline. In 2012, the FDA approved the LINX procedure, or magnetic sphincter augmentation, as a minimally invasive alternative to traditional surgical approaches for GERD. Despite its initial adoption, there is limited data on the recent utilization trends for both traditional and newer antireflux surgeries. We aimed to examine the trend of antireflux surgery, including surgical fundoplication and the LINX procedure, using a nationwide healthcare database over a span of 25 years.
Methods: We conducted a cohort analysis using data from TriNetX, a US-based healthcare database, identifying GERD patients – including those with Erosive Esophagitis [EE], Nonerosive Reflux Disease [NERD], and Barrett’s Esophagus [BE] – from 1999 to 2023. Antireflux surgeries were identified through CPT codes, including all forms of surgical fundoplication and the LINX procedure. Annual incidence rates were calculated as new cases per 100,000 GERD patients, with subgroup analyses by age (?65 vs. <65 years), sex, GERD phenotype (EE, NERD, and BE), and BMI (?35 vs. <35 kg/m2). We employed the joinpoint regression method to evaluate trend changes and calculate the annual percentage change (APC) and 95% confidence intervals (95%CI).
Results: Between 1999 and 2024, we identified 62,356 antireflux surgeries, including 1,679 LINX procedures. Trend analysis revealed a significant decline in antireflux surgery utilization from 1999 to 2008 (APC -8.55%; 95%CI -18.83% to -2.42%; p=0.02). However, this was followed by a substantial increase from 2008 to 2012 (APC +59.85%; 95%CI 29.52% to 102.60%; p=0.01), with a continued rise from 2012 to 2023 (APC +16.51%; 95%CI 6.32% to 21.42%; p=0.03). LINX procedure data, available starting in 2016, showed an initial surge in utilization until 2018 (APC 410.65%; 95%CI 79.33% to 1,035.84%; p<0.001), followed by a significant decline from 2018 to 2023 (APC -27.65%; 95%CI -61.74% to -4.65%; p=0.02).
Subgroup analyses indicated that patients with EE and BE were more likely to undergo antireflux surgery. Interestingly, while females had higher overall rates of antireflux surgeries, the majority of LINX procedure patients were performed on males. There were no significant differences in incidence rates by age or BMI.
Conclusion: Our study revealed a resurgence in surgical fundoplication utilization following 2008, contradicting prior reports of a sustained decline in antireflux surgeries. Conversely, interest in the LINX procedure has diminished in recent years after an initial rise. These findings underscore shifting trends in antireflux surgery utilization and highlight demographic differences across procedures.
Figure 1. Incidence Rates of (A) All Antireflux Surgeries and (B) LINX Procedure only. Subgroup analysis for (C) All Antireflux Surgeries and (D) LINX Procedure based on three GERD phenotypes (EE, NERD, BE)
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